[Robotic approach to hepatobiliary surgery. German version]

Robot-assisted hepatobiliary surgery has been steadily growing in recent years. It represents an alternative to the open and laparoscopic approaches in selected patients. Endowristed instruments and enhanced visualization provide important advantages in terms of selective bleeding control, microsuturing, and dissection. Cholecystectomies and minor hepatectomies are being performed with comparable results to open and laparoscopic surgery. Even complex procedures, such as major and extended hepatectomies, can have excellent outcomes, in expert hands. The addition of indocyanine green fluorescence provides an additional advantage for recognition of the vascular and biliary anatomy. Future innovations will allow for expanding its use and indications. Robotic surgery has become a very important component of modern minimally invasive surgery and the development of new robotic technology will facilitate a broader adoption of this technique.

A statistical approach to discriminate between non-fallers, rare fallers and frequent fallers in older adults based on posturographic data

BACKGROUND

Identification of future non-fallers, infrequent and frequent fallers among older people would permit focusing the delivery of prevention programs on selected individuals. Posturographic parameters have been proven to differentiate between non-fallers and frequent fallers, but not between the first group and infrequent fallers.

METHODS

In this study, postural stability with eyes open and closed on both a firm and a compliant surface and while performing a cognitive task was assessed in a consecutive sample of 130 cognitively able elderly, mean age 77(7)years, categorized as non-fallers (N=67), infrequent fallers (one/two falls, N=45) and frequent fallers (more than two falls, N=18) according to their last year fall history. Principal Component Analysis was used to select the most significant features from a set of 17posturographic parameters. Next, variables derived from principal component analysis were used to test, in each task, group differences between the three groups.

FINDINGS

One parameter based on a combination of a set of Centre of Pressure anterior-posterior variables obtained from the eyes-open on a compliant surface task was statistically different among all groups, thus distinguishing infrequent fallers from both non-fallers (P<0.05) and frequent fallers (P<0.05).

INTERPRETATION

For the first time, a method based on posturographic data to retrospectively discriminate infrequent fallers was obtained. The joint use of both the eyes-open on a compliant surface condition and this new parameter could be used, in a future study, to improve the performance of protocols and to verify the ability of this method to identify new-fallers in elderly without cognitive impairment.

Peripheral inflammatory response in Alzheimer's disease and multiinfarct dementia

Whether peripheral inflammatory molecules can be considered markers of dementia is still an open issue. We have investigated the presence of circulating cytokines and the ability of blood cells to release them in response to an inflammatory stimulus in patients with different types of dementia and in age-matched controls. A significant increase in circulating interleukin-1beta in moderate Alzheimer and in multiinfarct (145 and 224 times control concentration, respectively) dementia and in circulating tumor necrosis factor-alpha concentration in multiinfarct dementia patient group (156%) were found. Tumor necrosis factor-alpha and interleukin-6 released from blood cells after exposure to lipopolysaccharide were significantly reduced in moderate Alzheimer (60%, both cytokines) and multiinfarct patients (71 and 50%, respectively), while interleukin-10 was decreased only in multiinfarct patients (61%). The results show that patients with Alzheimer disease or multiinfarct dementia have an upregulation of circulating cytokines and a downregulation of cytokines released by blood cells.

Inflammatory markers in Alzheimer's disease and multi-infarct dementia

Inflammation has been involved in the pathogenesis of dementia. The study evaluates the presence and the source of pro- and anti- inflammatory cytokines in the blood of patients with Alzheimer's disease (AD), multi-infarct dementia (MID) or in non-demented elderly people (controls). Tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-6, IL-10, IL-1 receptor antagonist (IL-1Ra) and soluble TNF receptor I (sTNF-RI) plasma concentrations and release from blood cells stimulated with lipopolysaccharide (LPS, 1 microg/ml) were determined. The results show that TNF-alpha released from blood cells is significantly decreased (27%) in all demented patients compared to controls. Circulating TNF-alpha is increased (400%) only in MID patients. In these patients plasma levels of sTNF-RI are increased (53%) and IL-10 from stimulated blood cells decreased (47%) compared to non-demented subjects. The results show that: (1) peripheral production of TNF-alpha is blunted in demented (both AD and MID) patients compared to non-demented age-matched subjects; (2) AD patients have a selective disregulation of the peripheral TNF-alpha system; (3) different cytokines are up- or down- regulated in MID patients showing that in this condition the pro- and anti-inflammatory peripheral cytokine system is more widely affected.

Apolipoprotein E and intronic polymorphism of presenilin 1 and alpha-1-antichymotrypsin in Alzheimer's disease and vascular dementia

Apolipoprotein E (ApoE) genotypes, presenilin 1 (PS-1) and alpha(1)-antichymotrypsin (ACT) polymorphism and the association of the genotypes were examined in patients with Alzheimer's disease (AD, n = 121) or vascular dementia (VD, n = 68) in comparison with elderly controls (n = 125). The frequency of the ApoE epsilon 4 allele was significantly increased both in late-onset AD (0.35) and in VD (0.17); the frequency of ApoE epsilon 2 was significantly reduced in AD, but it was similar in VD and controls. The presence of the allele 1 of PS-1 intronic polymorphism was not associated with AD or VD and was not influenced by the ApoE genotypes. Also, the frequency of allele A of the intronic polymorphism of ACT was similar in AD, VD and controls and it was not altered by ApoE or PS-1 genotypes. The results confirm the association between ApoE epsilon 4 and AD and indicate an increase in ApoE epsilon 4 in Vd, too. A potential protective role of ApoE epsilon 2 is also suggested for late-onset AD but not for VD. No association was shown between ACT allele A and PS-1 allele 1 in AD or VD.

Superior thyroid artery lesion after US-guided chemical parathyroidectomy: angiographic diagnosis and treatment by embolization

A 71-year-old woman presented with a life-threatening thyroid hemorrhage after US-guided chemical parathyroidectomy. The diagnosis was made by angiography followed by immediate embolization of a pseudoaneurysm of the left superior thyroid artery. Embolization controlled the hemorrhage, obviating the need for surgery. The patient made a full recovery with no evidence of further hemorrhage. Pseudoaneurysm of the superior thyroid artery is a rare cause of hemorrhage and percutaneous embolization is an effective method of treatment.

[A case of postprandial hypotension in an elderly subject]

This is a case report of a 74-year old woman who from March 1994 to April 1995 was admitted to our hospital because of three episodes of syncope. Each general physical examination was normal except for a grade 2/6 systolic murmur. No abnormalities were disclosed after several resting electrocardiograms and Holter monitoring. The Schellong and the tilt tests were normal. During the last admission the patient had a syncope 30 minutes after a meal. Blood pressure reduction was documented and postprandial hypotension was diagnosed. Postprandial decreases in systolic blood pressure in the elderly may predispose the subject to symptomatic hypotension and to falls, dizziness, weakness, angina pectoris, stroke and syncope. The mechanism of postprandial hypotension is not fully understood. It is defined as a decrease in postprandial systolic blood pressure of 20 mmHg or more. Because postprandial hypotension is a common problem in older, frail, institutionalized patients, all physicians caring for elderly patients should be aware of the hypotensive effects of food intake and should consider postprandial hypotension in the evaluation of falls, syncope and other ischemic cerebral symptoms.

Lipomatous tumors of the uterus: ultrasonographic findings in 11 cases

We reviewed the ultrasonographic findings in eight patients with 11 lipomatous uterine tumors studied with transabdominal (eight cases) and transvaginal (six cases) techniques. A transvaginal color Doppler study was obtained in five patients. Two patients had more than one nodule (two and three uterine nodules, respectively). All lipomatous tumors had regular margins and were hyperechoic. Transvaginal sonography allowed the identification of one small previously undetected tumor but was not able to image the entire extent of two large lipomatous masses. In one case, it helped to establish the actual uterine origin of an eccentric pelvic mass. Color Doppler sonography showed complete absence of flow in all tumors examined. We believe that lipomatous tumors of the uterus can be diagnosed with a high degree of certainty by ultrasonography if a homogeneously hyperechoic avascular mass can be clearly identified to be of uterine origin.

High resolution sonography of the flexor tendons in trigger fingers

A sonographic study was conducted to analyze changes of the flexor tendons in patients with trigger fingers. We evaluated thickness and echotexture of the flexor tendons of the fingers in 54 patients with 66 symptomatic digits using 10 and 13 MHz "small parts" transducers; the results were compared with those observed in 20 normal controls. Images were obtained on the volar surface of the hand, at the head of metacarpals, and at the base of first phalanx, where the first annular pulley of the digital canal is located and where the changes occurring during passive assisted extension of the fingers were evaluated. Normal tendons were 2.9 to 4.4 mm thick (mean, 3.71 +/- 0.46) and had fibrillar echotexture. Patients had tendons ranging from 3.8 to 6.7 mm (mean, 5.41 +/- 0.94); the difference from controls was highly significant (P < 0.001). A cyst was attached on the volar surface of the involved tendons in 15 cases. Diffuse thickening of the synovial sheath was present in 20 tendons, whereas 17 tendons had irregular internal echotexture. Extension movements caused changes in shape of both cysts and peritendinous envelopes. In conclusion, sonography seems able to identify a variety of pathologic changes affecting tendons in these patients and may help both to explain the pathophysiology of their clinical situation and guide therapeutic decisions.

[Retrospective analysis of color Doppler ultrasonography and flowmetry findings in solid nodular pathology of the breast]

The authors tried to identify useful flowmetric values and color-Doppler patterns for the differential diagnosis between benign and malignant solid breast lesions. To this purpose, 106 patients with breast nodules detected at mammography and/or high resolution US were examined. A US scanner with a linear 7.5 MHz transducer, a narrow sample volume, a PRF ranging (650-800 Hz) and a wall filter value of 50 Hz were used. Three parameters were considered: the number vascular sites, systolic peak velocity and pulsatility index. All these parameters related to tumor volume. Several (> 2) vascular sites, high peak velocity and quite high pulsatility index were demonstrated in malignant tumors (46 lesions). Among benign tumors no vascular site was identified in 32 of 60 lesions and no more than 2 sites were identified in 26 of 60 lesions, except for 2 phylloides tumors. Sensitivity, specificity, positive and negative predictive values and overall accuracy rates were, as for the "vascular sites" parameter, 78%, 96%, 94%, 85%, 88%, respectively; as regards the "peak systolic velocity" 81%, 86%, 89%, 75%, 83% respectively; as regards the "pulsatility index" 100%, 85%, 100%, 85%, 94% respectively.

[Doppler color-echo and flowmetric evaluations in ovarian tumors in postmenopausal patients]

The use of color Doppler techniques in transvaginal sonography (US) permitted the identification of some typical flowmetric patterns of malignant ovarian cancers, because of such characteristics of neoplastic vessels as no media in the vessel wall, the presence of A-V shunts, and so on. These features reduce vascular impedance, from which low pulsatility index and resistance index values result. Eighty-one patients with ovarian masses were examined: in 19 of them histopathology revealed malignant lesions in different stages. Eighteen of those lesions exhibited suspect transvaginal patterns; in one case only the US patterns suggested a benign lesion, which was a serous cystadenocarcinoma with thin and regular septa. In all the malignant lesions flow could be sampled in six sites at least; the lowest pulsatility index values, obtained by multiple samplings in the same lesion, were considered as the most representative of the histologic features of the lesion. The average of the lowest pulsatility index values in 18 of 19 malignant lesions was 0.75. In one case only (the only false negative in the series) the lowest pulsatility index value was 1.20. Doppler signals were detected in 58 of 62 benign lesions only and the average of the lowest pulsatility index values was 1.80. The only kind of condition with low pulsatility index was the inflammatory disease (all the 6 sampled cases). If we consider a pulsatility index < 1 as the cut-off value for malignant lesions, the sensitivity and the specificity of color Doppler US were 95% and 91%, respectively, in our series. The positive predictive value of the exam was 75% and its negative predictive value was 95%.

Hypothyroidism presenting as destructive arthropathy of the fingers

A patient presenting with destructive arthropathy of the proximal interphalangeal (PIP) joints of the hands is described. She was initially believed to have rheumatoid arthritis but non-steroidal anti-inflammatory drugs were of no help. The patient was subsequently found to have hypothyroidism and erosive osteoarthritis of the fingers. Joint swelling, pain and stiffness responded dramatically to thyroid hormone substitution. The PIP joint spaces reappeared on the radiographs within 9 months. This case suggest that hypothyroidism may induce destructive arthropathy of the finger joints. As thyroxine replacement may reverse the rheumatic complaints, hypothyroidism should be considered in the differential diagnosis of a destructive arthropathy of unclear aetiology.

Refsum's disease: management by diet and plasmapheresis

A case of Refsum's disease treated by serial plasma exchanges together with a moderate low phytanate diet is reported. Serial plasma exchanges determined a rapid significant clinical improvement (neuropathy and cerebellar ataxia) that allowed immediate return to full-time employment. The initial improvement could be maintained by intermittent serial plasmapheresis despite partial failure of the initially introduced low phytanate diet bringing 20 mg phytanic acid daily. A new dietary regimen bringing 10 mg phytanic acid was later introduced that was well tolerated. No liquid formula was used. The clinical improvement was clearly correlated to a fall in serum phytanic acid from 45.3 to 16.2 mg/100 ml.